Patient-Safety-Learning

On his last day in office as Chief Investigator at the Healthcare Safety Investigation Branch (HSIB), Keith Conradi sent this letter to the Secretary of State for Health and Social Care, outlining his concerns about the approach of the Department of Health and Social Care (DHSC) and NHS England to patient safety work carried out by HSIB. In his letter, Keith highlights a lack of interest in HSIB investigations and activity from leaders in both NHS England and DHSC, and describes how this attitude permeates both organisations. He also draws attention to a lack of priority and support for patient safety at a structural level, and calls on government and healthcare leaders to take a new approach and introduce a regulated safety management system with appropriate accountability. Patient Safety Learning has written a blog reflecting on Keith Conradi's letter, highlighting the ways in which his concerns align with those consistently raised by Patient Safety Learning.

The National Audit of Care at the End of Life (NACEL) is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP). It was carried out by the NHS Benchmarking Network in collaboration with The Patients Association and aims to assess the quality of care that patients receiving end of life care and their families experience, as well as staff perceptions of their confidence and ability to deliver end of life care. The audit included: an Organisational Level Audit covering Trust/Health Board and hospital/submission level questions for 2020/21. a Case Note Review which reviewed 20 consecutive deaths between 12th April 2021 and 25th April 2021 and 20 consecutive deaths between 1st May 2021 and 14th May 2021 for acute providers and up to 40 consecutive deaths in April and May 2021 for community providers. a Quality Survey completed online, or by telephone, by the bereaved person. a Staff Reported Measure, completed online. Key findings Recognising the possibility of imminent death The possibility that the patient may die within the next few hours/days was recognised in 87% of cases audited, compared to 88% in 2019. The median time from recognition of dying to death was recorded as 44 hours (41 hours in 2019). Communication with the dying person Results on all key metrics regarding the recording of conversations with the dying person remain similar to 2019, pre-pandemic levels However, from the Quality Survey, the proportion strongly disagreeing or disagreeing with the statement ‘staff communicated sensitively with the dying person’ increased from 7% (2019) to 11% (2021). Communication with families and others There was little change in 2021 when compared to 2019, with continued high compliance on recording of conversations about the possibility that the person might die and on the individualised plan of care. As in 2019, discussions on hydration and nutrition with families and others were documented, or a reason why not recorded, in only around half of cases. Involvement in decision making Findings from the Case Note Review in 2021 suggest continued strong compliance on involvement in decision making, with similar results to those reported when this theme was last tested in 2018. However, from the Quality Survey, in 2021, 23% of people felt they would like to be more involved in the person’s care compared to 19% in 2019. Individualised plan of care Third round findings from the Case Note Review showed similar results for the existence of an individualised plan of care, 73% of cases compared to 71% in 2019, suggesting this is an ongoing area for improvement. Documented evidence of an assessment of wider needs such as emotional/psychological, spiritual/religious/cultural and social/practical shows a reduction since 2019, which may be a result of continuing pressures of the Covid-19 pandemic on services during 2021. Needs of families and others The needs of the family were identified as an improvement area in both round one and round two of the audit. Comparison with 2019 findings suggests performance has deteriorated, which may reflect the impact of the pandemic on the ability of visitors to access wards and the capacity of staff to assess and address the needs of families and others. Families’ and others’ experience of care The overall rating of care and support to the person who died, and the overall rating of care and support provided to families and others, are lower than in 2019. Governance Governance was last measured in 2018 and Trusts/Health Boards (HB) continue to show high compliance with the existence of key policies related to care at the end of life in 2021. Workforce/specialist palliative care The results show an improvement in access to specialist palliative care, in particular, face-to-face access 8 hours a day, 7 days a week was available in 60% of hospitals/sites compared to 36% in 2019. The increased provision may reflect a response to the pandemic and it is not yet clear whether the change will be permanent. Staff confidence Staff completing the survey expressed confidence in recognition of dying, communication, responding to the needs of the dying person and those important to them, involving people in decision making, accessing specialist palliative care and managing pain and physical symptoms, with less than 6% stating they strongly disagreed or disagreed with positive statements of confidence in these areas. Staff support Training was identified as a potential area for improvement with only 49% of respondents stating they had completed training specific to end of life care within the last three years. Although staff felt support was available from the specialist palliative care team, only 66% felt managerial support was available to help provide care at the end of life. Care and culture Although 83% felt able to raise a concern about end of life care, this should be closer to 100%. Only 80% answered positively that they felt they work in a culture the prioritises care, compassion, respect and dignity, which is also a concern.

Some patients are unable to tolerate imaging procedures such as MRIs due to pain or anxiety. In these cases, a variety of medications are routinely used prior to imaging to allow the procedure to be carried out successfully. Varying levels of sedation before imaging can be appropriate given the need for patients to remain still during the imaging process, but the minimal amount of sedation should be used to mitigate unwanted side effects and reduce the risk of adverse events. This article examines two cases that highlight the risks of minimal-to-moderate sedation for imaging procedures, especially in high-risk patients, when multiple medication doses are required and when monitoring is limited or inadequate.

In this blog, nurse Carol Menashy describes her experience making an error in theatre fifteen years ago, and the personal blame she faced in the way the incident was dealt with at the time. She talks about how a SEIPS (Systems Engineering Initiative for Patient Safety) framework can transform how adverse incidents are dealt with, allowing healthcare teams to learn together and use incidents to help make positive changes towards patient safety. She describes the progress that has been made towards organisational accountability and systems thinking over the past fifteen years, and talks about the importance of staff support to allow for healing from adverse events.

This study in the journal Infection Control & Hospital Epidemiology aimed to determine the extent to which asymptomatic individuals infected with Covid-19 transmitted the disease to other patients and staff on a hospital ward. The authors found that a comprehensive symptoms and signs assessment, in combination with adequate follow-up, allows for a more precise determination of Covid-19 symptoms. The results of the study revealed that asymptomatic infection was quite uncommon amongst adults in this setting.

This is the annual report of the National Diabetes Inpatient Audit–Harms (NaDIA-Harms) programme, which aims to monitor and reduce instances of key life-threatening diabetes specific inpatient events. The programme covers hypoglycaemic rescue, diabetic ketoacidosis (DKA), hyperosmolar hyperglycaemic state (HHS) and diabetic foot ulcer. Overall 4,605 inpatient harms were submitted to the NaDIA-Harms audit between May 2018 and October 2020; the majority of which related to hypoglycaemic rescue (69%). This report also covers: the number of submissions of each inpatient harm. the impact of the Covid-19 pandemic on inpatient harms. patient profiles of people that experience each inpatient harm. These include demographics, diabetes characteristics, treatment targets, care processes, admission characteristics and comorbidities.

There has been an increase in the use of video group consultations (VGCs) by general practice staff, particularly since the beginning of the Covid-19 pandemic, when in-person care was restricted. This qualitative study in the British Journal of General Practice aimed to examine the factors affecting how VGCs are designed and implemented in general practice. Through semi-structured interviews with practice staff and patients, the authors found that: in the first year of the pandemic, VGCs focused on supporting those with long-term conditions or other shared health and social needs. most patients welcomed clinical and peer input, and the opportunity to access their practice remotely during lockdown. not everyone agreed to engage in group-based care or was able to access IT equipment. significant work was needed for practices to deliver VGCs, such as setting up the digital infrastructure, gaining team buy-in, developing new patient-facing online facilitation roles, managing background operational processes, protecting online confidentiality, and ensuring professional indemnity cover. national training was seen as instrumental in capacity building for VGC implementation.

Cancer screening involves testing for early signs of cancer in people without symptoms. It can help spot cancers at an early stage, when treatment is more likely to be successful, or in some cases prevent cancer from developing the first place. The screening test for bowel cancer is the faecal immunochemical test, or FIT, that looks for tiny traces of blood in your poo. These tests are sent to everyone in the eligible population every two years. In this blog Jacob Smith from Cancer Research UK looks at the importance of increasing bowel cancer screening in socioeconomically deprived communities, where there is a higher incidence of bowel cancer and death from bowel cancer. This is partly due to lower levels of participation in screening. The blog highlights the results of a recent study carried out by the University of Sheffield to determine which interventions may be successful in reducing health inequalities related to bowel cancer screening. Modelling found that re-inviting non-participants to take part in screening each year was a highly effective intervention, and it is estimated that this approach would prevent over 11,000 bowel cancer deaths over the lifetime of the current English population aged 50-74.

This report by the All Party Parliamentary Group (APPG) on Muslim Women and the Muslim Women's Network UK aimed to investigate the maternity experiences of Muslim women in the UK, particularly from Black, Asian and other minority ethnic backgrounds. It aimed to better understand the factors that influence the standard of maternity care Muslim women receive, and to determine whether this may be contributing to poorer outcomes for them and their babies. 1,022 women completed surveys and 37 women were interviewed for the research. The study focused on the care given throughout pregnancy in the antenatal, intrapartum and postnatal periods. Experiences of sub-standard care were analysed to find out: whether they were associated with the women’s intersecting identities such as ethnicity, religion and class. whether attitudes were due to unconscious bias (for example, negative stereotypes or assumptions) or conscious action (for example, microaggressions). what role (if any) organisational policies and practices played. Particular attention was paid to how near misses occurred as this information could help to save lives of mothers and babies. To show what good practice looks like, positive experiences were also highlighted.

People with diabetes are increasingly using medical devices to help manage their condition, including devices for monitoring glucose and delivering insulin. However, healthcare professionals are finding that they cannot always access up to date information about a person with diabetes and the data from their medical devices. This makes it harder to provide the best advice and support. The Professional Record Standards Body (PRSB) was commissioned by NHS England and NHS Improvement to produce two standards for sharing diabetes information between people and professionals across all care settings, including self management data from digital apps and medical devices (for example, continuous glucose monitors). The Diabetes Information Record Standard which defines the information needed to support a person’s diabetes management. It includes information that could be recorded by health and care professionals or the person themselves that is relevant to the diabetes care of the person and should be shared between different care providers. The Diabetes Self-Management Standard which defines information that could be recorded by the person (or their carer) at home (either using digital apps or medical devices) and shared with health and care professionals.

In this presentation Paula Goss, the founding member of Rectopexy Mesh Victims and Support, shares her experience of having a mesh implant. She describes the absence of informed consent during the procedure and the pain and complications she experienced following her surgery. This was shared at a Bristol Biomedical Research Centre workshop aimed at improving shared decision making for surgical innovation.

An increasing number of healthcare artificial intelligence (AI) applications are in development or already in use, but the safety impact of using AI in healthcare is largely unknown. This qualitative study in the journal Safety Science aimed to explore how different stakeholders (patients, hospital staff, technology developers and regulators) think about safety and the safety assurance of healthcare AI. Through a series of interviews, the authors assessed stakeholder perceptions of an AI-based infusion pump in the intensive care unit. Participants expressed perceptions about: the potential impact of healthcare AI requirements for human-AI interaction safety assurance practices and regulatory frameworks for AI and the gaps that exist how incidents involving AI should be managed. The authors concluded that there is currently a technology-centric focus on AI safety, and a wider systems approach is needed. They also identified a need for greater awareness of existing standards and best practice among technology developers.

This guide developed by the AHSN Network, the University of Plymouth and the pharma company Boehringer Ingelheim sets out four key principles to involve and engage patients and the public in digital health innovation: Engage – map out your strategy and motivations, identify a representative cohort and develop inclusive engagement practices. Acknowledge, value & support – show you value patients’ and the public’s contribution to ongoing and transparent communication, any necessary training and potential financial reimbursement. Communicate – tailored external communication and open feedback channels are crucial to maintaining engagement and accountability by all parties. Trust and transparency – In order to gain patients’ trust, organisations conducting PPIE should be trustworthy and transparent about potential risks.

In this briefing paper for the Social Market Foundation, Lord Norman Warner sets out a radical change programme that could reverse the decline in NHS services. It examines long-term issues that have been exacerbated by the impact of Brexit and the Covid-19 pandemic—the care backlog, workforce issues and loss of public confidence.

It is important that patients understand the risks, benefits and alternatives associated with their treatment, but there is often a gap in patients' actual understanding of these issues. There is now substantial evidence showing that patient decision aids (PDAs) and shared decision making can bridge the gap between the theory and practice of informed consent. However, in spite of the evidence, PDAs are still rarely used in clinical settings. This article in the journal Maine Law Review looks at how the monetary incentive of a professional liability insurance premium reduction could encourage doctors in the USA to increase the use of PDAs.

Patients recovering from an episode in an intensive care unit (ICU) frequently experience medication errors on transition to the hospital ward. This systematic review in BMJ Quality & Safety aimed to examine the impact of medication-related interventions on medication and patient outcomes on transition from adult ICU settings and identify barriers and facilitators to implementation.

Healthcare is traditionally a hierarchical industry. This structure can foster a culture of division amongst staff that is sometimes made worse by significant differences in background and training. However, in order to make sure care is safe and of a high quality, healthcare teams must develop good teamwork and communication. This is only possible if every member of the team feels respected and is free to speak up when they think something is wrong. In this podcast, host David Feldman speaks to Michael Brodman, Professor and Chair Emeritus in the Department of Obstetrics, Gynecology, and Reproductive Science at the Icahn School of Medicine at Mount Sinai in the US. They discuss how mutual respect is essential for any institution developing a culture of safety and how the problems presented by medical hierarchy can be overcome.

This blog by doctors Clare Rayner and Amali Lokugamage argues that Long Covid rehabilitation needs a wider focus that goes beyond a purely biomedical paradigm to include complementary therapies and methods. The authors—who have both lived with Long Covid for more than two years—argue that although patients were the first to raise concerns about Long Covid, describe its symptoms and patterns and even research the condition, their narratives and voices are not being included in approaches to treatment. While the biomedical evidence surrounding Long Covid is currently limited, they highlight that there is much valuable lived-experience to be found in patient support and campaign groups, and that patients' knowledge should be drawn on to shape policy and guidance about the condition.

This guidance was updated on the 30 June 2022 to clarify how healthcare professionals should apply the term “unexpected or unintended” to decide if something qualifies as a notifiable safety event or not. Further detail is included below and you can find the full update here.

This blog by the charity Mental Health UK looks at an innovative project that aims to transform the way care and support are delivered to people living with severe mental illness in Grimsby and Bridgend. It aims to meet people’s mental health needs by providing tailored support, signposting them to specialist services to improve their quality of life, prevent the need for emergency crisis care and reduce pressure on acute medical services. The project is being run in conjunction with healthcare company Johnson & Johnson UK, with the support of the local NHS. The project involves Community Mental Health Navigators supporting the non-medical needs of people living with severe mental illness, such as bipolar disorder, schizophrenia and borderline personality disorder. They provide support with aspects of people’s lives which can drive poor mental health, such as housing, money problems, employment, physical wellbeing and lack of social connections.

This online community has been set up by the Care Quality Commission (CQC) to engage with members of the public on a range of topics related to the CQC's work as regulator of health and social care services in the UK. The site invites people to get involved in different ways, for example: by sharing expertise, experience and thoughts through discussions. by reviewing documents. by taking part in polls and surveys. by contributing to idea boards. When signing up, you can either use your own name or your organisation’s name, and you'll be asked to choose what groups you represent and what sectors you work in or use.

In this blog, Dr Chloe Stewart, health psychologist and national clinical advisor in personalised care for NHS England, looks at the role of personalised care in helping overcome the care backlog and addressing health inequalities in people with musculoskeletal conditions (MSKs). She looks at examples of coproduction in MSK services and highlights the need to give patients better information and training about how to manage their condition.